Characterising the behaviours in most severe and least severe emotional outbursts in young people

Emotional outbursts are displays of intense, challenging behaviour and are prevalent in individuals with neurodevelopmental disorders. Outbursts present a danger to individuals and their carers and are cited as reasons for referral to mental health services. However, it is currently unclear how the characteristics of outbursts may determine their severity. Carers (n = 214) of individuals aged between 6 and 25 and experiencing outbursts at least once per month completed the Emotional Outburst Questionnaire. Questionnaire items were used to compare behaviours observed in most severe and least severe outbursts through quantitative and content analyses of open ended data. Signs of physiological arousal and aggression were seen significantly more in most severe outbursts compared to least severe outbursts. Least severe outbursts were seen more frequently, but most severe outbursts were reported to have a longer duration, be at a higher intensity, and have a longer recovery time. Additionally, associations were found between reduced eye contact and most severe outbursts, as well as expression of suicidal ideation and most severe outbursts. Certain behaviours, notably forms of aggression and physiological arousal, are associated with most severe outbursts. Findings of this study may allow future work examining cross-disorder differences in outbursts to inform targeted interventions aiming to reduce outburst severity and impact. Additionally, identification of such outburst characteristics could aid in measurement of outburst severity, which would allow for more reliable and valid studies on outburst interventions.

The full list of diagnoses and frequencies can be found in Appendix A.
Percentage adds up to more than 100 as some participants listed multiple diagnoses.

Attempts at de-escalation 1
Behaviour indicative of emotion 67

Bodily responses 6
Caregiver label of anger 27

Caregiver label of anxiety 11
Caregiver label of distress 14

Dramatic behaviours 1
Drug use 1

Duration of 20 mins or longer 51
Duration of less than 20 mins 8

Easier to resolve 2
Easily triggered 2

Escape behaviours 32
Expression of remorse during or after an outburst 1

Expressions of suicidal ideation 9
External triggers 0

Increased motor activity 28
Increased non-word sounds 2

Negative emotional impact on carer 6
Obsessional behaviours or thoughts 0

Repetitive behaviours 15
Seeks support from caregiver 1 Self-deprecating behaviour 4

Shutting down behaviour 13
The individual has no control/awareness during the outburst 31

Triggered by bodily state indicators of low resources 0
Triggered by fear 0
In this questionnaire, we want you to think about the most severe and least severe emotional outbursts within the past month that the individual you care for has displayed and the characteristics associated with each type of emotional outburst, such as behaviours, frequency, and duration.In terms of the severity of emotional outbursts, we are referring to how disruptive and negatively impactful they are to the person and/or those around them at the time of the emotional outburst.
If you feel that the severity of emotional outbursts is always the same, please answer the questions relating to the most severe type.We recognise that some questions may be difficult to answer, as emotional outbursts can vary greatly depending on the context.However, please try to give an average for these questions, as this will help us to better understand emotional outbursts over a range of contexts.
First, we would like you to consider the most severe emotional outbursts that the individual you care for has displayed within the past month.Now, we would like you to consider the least severe emotional outbursts that the individual you care for has displayed within the past month, that nevertheless disrupt and negatively impact them and/or those around them.We are referring to episodes that are different from the person's normal or baseline behaviour.The term "emotional outburst" refers to a highly emotional or explosive episode, where at least one of the behaviours listed above (items 2-23) is displayed.Emotional outbursts may also be known as "meltdowns", "crisis", "behavioural breakdown", "blips", "rages", "temper outbursts", "tantrums", or "tempers".
If you feel that the severity of emotional outbursts is always the same, please tick the 'Not applicable' box below and continue from item 57.133 How often are you there to witness the emotional outbursts when they occur?

Appendix C Results of the content analysis in full Category description Frequency for MS Frequency for LS
Aggression towards property E.g., throwing objects, breaking things Arguing Including disagreement, answering back Attempts at de-escalation E.g., attempting to calm down or regain control Behaviour indicative of emotion E.g., crying, descriptions of facial expressions are signs of emotions Being inflexible E.g., fussy, outburst occurs if individual is asked to a less preferred activity Bodily responses Unintentional bodily responses such as vomiting, or inducing a headache or tiredness Caregiver label of anger Including anger, frustrated, rage Caregiver label of anxiety Including anicky, agitated Caregiver label of distress Including emotional, sad, upset Caregiver label of confusion E.g., confused, irrational thinking Contextually inappropriate behaviours E.g., inappropriate laughing, withdrawal into roleplay Defiance/refusal Including stubborn behaviours Demanding E.g., follows when walk away/demanding of attention/asking or pleading Difficult to resolve E.g., can't reason with the person Dramatic behaviours E.g., catastrophising Drug use E.g., alcohol or illicit drug use during outburst Duration of 20 mins or longer Duration of 20 mins or longer, or expression of extended/long duration Duration of less than 20 mins Duration of less than 20 mins, or expression of short duration Easier to resolve E.g., resolved by caregiver walking away, or caregiver saying that outbursts are easy to resolve Easily triggered Events perceived to be insignificant trigger the outburst Escape behaviours E.g., running off or dropping to the floor Negative emotional impact on carer Carer expressing feelings of hopelessness/sadness/fear Obsessional behaviours or thoughts Obsessional or compulsive behaviours occurring during outburst Occurs frequently Frequency of at least once a week Occurs rarely Frequency of less than once a week Perceived manipulation Caregiver perceiving individual's behaviour to be controlling or manipulative Perceived meanness E.g., rudeness, label of intentional mean behaviour Physiological arousal Such as red face, dribbling, tensed up Repetitive behaviours E.g., repetitive speech or movements Advice and support around protecting the individual you care for is available via the NSPCC, Papyrus, or Samaritans.We would like you to consider in general, all emotional outbursts the individual you care for has displayed within the past month.Please indicate your answer for each item by ticking the appropriate box (☐).